gait analysis and single-event multi-level surgery the melbourne experience
DESCRIPTION
Gait analysis and Single-event Multi-level surgery The Melbourne Experience. Richard Baker Professor of Clinical Gait Analysis. Clinical scientist. Member of IPEM Registered with HPC. Me!. MA Physics and Theoretical Physics PhD Biomechanical Engineering - PowerPoint PPT PresentationTRANSCRIPT
Gait analysis and Single-event Multi-level surgeryThe Melbourne ExperienceRichard BakerProfessor of Clinical Gait Analysis
Clinical scientist• Member of IPEM• Registered with HPC
Me!• MA Physics and Theoretical
Physics
• PhD Biomechanical Engineering
• 7 years Gait Analysis Service Manager Musgrave Park Hospital, Belfast
• 9 years Gait Analysis Service Manager Royal Children’s Hospital, Melbourne
Melbourne, Victoria
Population
Victoria 5.5 millionMelbourne 4.1 million
(Greater Manchester 2.6 million)
120 new cases of CP annually
Royal Children’s Hospital
Optimising gross motor function for children with CPDoing the simple things well
Optimising gross motor function for children with CP• GMFCS (Gross motor classification system)• Age• Unit/bilateral involvement• Motor type• (CP like conditions)
Level I
Level V
Level III
Level II
Level IV
GMFCS
Palisano et al. DMCN 1997
Revised and extended Palisano et al. DMCN
2008
Robin et al. JBJR-Br 2008
GMFCS and age
Impairments and age
Spasticity
Muscle ContractureJoint contractureBony deformity Weakness
BotoxITBSDR
Exercise?Strenghtening?
Diet?SEMLS
Physiotherapy and orthoses
SEMLS
• Minimum of one procedure at two levels (hip/knee/ankle) on both sides
Typical SEMLS
• Psoas recession• Femoral derotation osteotomy• Semitendinosus transfer• Gastrocnemius recession• Calcaneal lengthening
SEMLS – who for
• GMFCS I rare (too good)• GMFCS II• GMFCS III• GMFCS IV rare (too bad)• GMFCS V never
SEMLS – Why?
ICF WHO 2001
SEMLS – Why?
• Improve gross motor function (not just walking)
• Prevent deterioration
• Increase activity and participation?• Improve quality of life?
SEMLS – When?
• After – maturation of gross motor performance– consolidation of skeleton (particularly feet)
• Before– increased education demands– grumpy adolescence
Pre-operative Processes
• Spasticity management in early childhood
• Surgeon decides surgery is required (8-10 years old)
• Pre-op gait analysis to determine nature of surgery
Pre-admission clinic
• Admitted as “day case”• Child and family get to meet ward
staff• Equipment arranged(orthoses,
walking aids, other OT)• Rehabilitation discussed• Consultation with community physio
In-patient
In-patient • 7 days• No rehab• Appropriate lying
0-3 months
Restricted mobility and therapy• Non weight-bearing 3 weeks• Cast change at 3 weeks• Orthoses delivered 6 weeks.• 6-12 weeks back on feet with Solid
AFOs walking with frame or crutches• 12 weeks: 1st post-op video session
3-6 months
Intensive therapy• Community based (home/school)• Move off frame/crutches• Extending walking distances• Maintain knee extension• 6 months: 2nd post-op video
6-12 months
Routine therapy• Community based (home/school)• Maintain progress• Move off crutches/sticks• Move to hinged orthoses?• 9 months: 3rd post-op video session• 12 months: post-op gait analysis
(outcome assessment)
12-24 months
• Optimum function will not generally be achieved until into the second year.
Video sessions
• Standardised video recording and simplified clinical exam.
• Review by specialist physiotherapist in person and surgeons by video.
• Review progress (walking aids and orthoses)
• Ensure knee extension.
PIP fundINTERVENTION HOURS PROVIDED
Botox – calves only 6 hours
Botox – multilevel 12 hours
Single level surgery – hemiplegia 6 hours
Single level surgery – diplegia 12 hours
Two level surgery – hemiplegia 12 hours
Two level surgery – diplegia 18 hours
Non-ambulant – hip surgery 12 hours
SEMLS – hemiplegia (bony and soft) 30 hours
SEMLS – diplegia (bony and soft) 70 hours
Gait analysis
• To identify impairments• Basis for planning surgery• Outcome assessment
Impairment focussed assessment
• Aims to identify impairments• Clearly link this to evidence from:
– Instrumented gait analysis– Physical examination
Report
Report
Report
Movement Analysis Profile
Movement Analysis Profile
RCT OF SEMLS
Thomason et al. JBJR-Am 2011
Participants
• 6-12 years old, GMFCS II or III• 11 in SEMLS group• 8 in control group
Results
pre 12 240.0
5.0
10.0
15.0
20.0
GPS scores for surgery and control groups (median and IQR)
surgerycontrol
GPS
(de
gree
s)
pre 12 2450.0
60.0
70.0
80.0
90.0
GMFM scores for surgery and control groups (mean and 95% CI)
surgerycontrol
GM
FM
pre 12 240.0
20.0
40.0
60.0
80.0
100.0
CHQ Physical function scores for surgery and control groups (mean and 95% CI)
surgerycontrol
GM
FM
AUDIT OF SEMLS
Rutz et al. ESMAC 2011
Participants
• All patients having SEMLS 1995-2008• 121 patients GMFCS II and III
• 48 girls, 73 boys• Age 10.7+/- 2.7
GMFCS
• 113 (93%) no change in GMFCS• 6 children from GMFCS III to II• 2 children from GMFCS II to I• No child deteriorated by GMFCS level
• Children who improved were either marginal or had evidence of earlier deterioration
MAP/GPS
Pelvic tilt
Hip flexion
Knee flexion
Ankle d'flex
Pelvic obliquity
Hip adduct'n
Pelvic rotation
Hip rotation
Foot prog.
GPS0
10
20
30
40
MAP components
Pre Post
Predictors of GPS change
• Age at surgery• GMFCS• GPS pre-op• No. of procedures• Adverse events• Private health insurance• Previous surgery
GPS
MAP
Pelvic Tilt
Hip Flexion
Knee Flexion
Ankle d'flex
Pelvic obliquity
Hip Adduct'n
Pelvic rotation
Hip rotation
Foot prog.
GPS-5
0
5
10
15
20
25
30
35Mod Severe Very Severe
Impr
ovem
ent
in g
ait
varia
ble
scor
e (d
egre
es)
MAP
0.0 10.0 20.0 30.0
-10.0
0.0
10.0
20.0
Short (1 year)Linear (Short (1 year))
Pre-operative GPS
Impr
ovem
ent
in G
PS
N = 47
MAP
0.0 10.0 20.0 30.0
-10.0
0.0
10.0
20.0
Short (1 year)Linear (Short (1 year))
Pre-operative GPS
Impr
ovem
ent
in G
PS
N = 28
Summary• SEMLS does not change GMFCS
status (but might restore it)• It can help improve walking (GPS)
and more general gross motor functions (GMFM)
Summary• Evidence of mild deterioration over
12 months in absence of intervention
• Optimal outcomes at 2 years, maintained for ten years
• More involved children appear to have more to gain